Inspection on 10/11/06 for St Margaret`s Ltd

This inspection was carried out on 10th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Margaret`s Ltd 05/05/09

St Margaret`s Ltd 08/05/08

St Margaret`s Ltd 30/05/07

St Margaret`s Ltd 19/06/06

St Margaret`s Ltd 26/01/06

St Margaret`s Ltd 18/07/05

St Margaret`s Ltd 09/12/04

St Margaret`s Ltd 23/06/04

St Margaret`s Ltd 05/01/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Margaret`s Ltd 3 - 5 Priestland`s Park Road Sidcup Kent DA15 7HR Lead Inspector Ms Pauline Lambe Unannounced Inspection 10th November 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Margaret`s Ltd Address 3 - 5 Priestland`s Park Road Sidcup Kent DA15 7HR Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8300 2745 020 8300 2745 Mr Al-Naseer Hudda Mrs Linda Masher Care Home 22 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (22) of places St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 22 Male or Female - OP (Old age) As agreed on the 3rd October 2006, one (1) named service user, with dementia, can be accommodated. The CSCI must be informed when this service user no longer resides at the home. 19th June 2006 Date of last inspection Brief Description of the Service: St. Margarets is privately owned by Mr and Mrs Hudda and has been registered since 1971. The home is registered to provide care and accommodation for 22 older people. The Home is a large detached two-storey property, which includes a purpose built extension. A lift is available for the residents. St Margarets is located in a residential area close to transport and shops. There are three double and sixteen single bedrooms, fourteen of which have en suite facilities. There are two bathrooms with WCs and three further WCs. A small lounge is situated at the front of the building. In addition there is a large lounge/dining room, which looks onto the attractive garden at the rear of the property. Residents have access to health care services via the local GP practice. The fees in the home at the time of inspection ranged between £435.00 and £565. Residents paid privately for personal items, hairdressing and newspapers. St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this unannounced inspection was completed on 10th November 2006 over 6.5 hours. The manager and staff assisted with the inspection. Twenty residents were in the home, one was in hospital and there was one vacancy. The service was last inspected on the 19th June 2006. The inspection included a review of information held on the service file, a tour of the premises, and inspection of records, talking to residents, relatives, staff and the manager and reviewing compliance with previous requirements. It was pleasing to see management had made efforts to address most of the requirements and recommendations made at the last inspection. Overall the management of the service had improved. It was however disappointing to see that little had been done to upgrade the environment and to learn that plans to do this had been put on hold. What the service does well: Management worked with the Commission to meet and improve standards. Practice in the home did not generate complaints. A high standard of care was provided. The home was kept clean and tidy and free of offensive odours. Management and staff worked to provide a homely atmosphere for residents. The home benefited from having a fairly stable staff team. St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? The statement of purpose was reviewed and updated. A service user guide was also provided. Residents were admitted based on an assessment of need and received written confirmation that based on the assessment the service was suited to meeting their needs. There were no residents in the home outside the home’s category of registration. Management had applied to the Commission for a variation to registration to care for one resident who suffered from dementia who had been admitted prior to the last inspection. Care plans continued to improve. Medicine management was now assessed as safe and did not pose a risk to residents. Staff had received update training on medicine management. A policy had been introduced in relation to residents self medicating. At residents request the provision of a roast dinner was changed from Monday to Sunday. Residents now also had a choice of a cooked meal at suppertime. The Policy and procedure in relation to adult protection had been amended and provided clear guidance on what action staff must take if abuse was suspected or alleged. All staff had received training on adult protection. Individual staff training records had been introduced. Six care and one domestic staff had been enrolled on a NVQ 2 course. Visits were made to the home as required by regulation 26 and reports sent to the Commission. Efforts had been made to implement a quality assurance system and resident and relative meetings had been held. A fire risk assessment had been completed on the property and fire drills held at times to include night staff. A competent person had provided fire safety training for staff. A system had been introduced to ensure hot water temperatures were checked regularly. A chef had been employed to work five days a week. A new carer had been employed and part of the role was to provide activities for residents two hours a day five times a week. St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, and 4. Standard 6 did not apply to the service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to the service. A statement of purpose and service user guide that complied with regulation was provided. Residents had assessments of need completed prior to admission. Residents received written confirmation that based on assessment the service was suited to meeting their needs. EVIDENCE: The statement of purpose was amended and complied with regulation. A copy had been sent to the Commission. A service user guide was provided and plans were in place to leave this information in a folder in resident bedrooms. St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 10 A copy of the last inspection report was displayed in the front hall and the registration certificate. Pre-admission assessments were seen on the resident files viewed. The manager completed these when a resident visited to view the home or wherever suited the prospective resident. Some files seen also contained detailed care manager assessments. Copies of the letter sent to residents confirming that based on assessment the home was suited to meeting their needs were seen on the files viewed. St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans continued to improve but still needed more detail on how assessed needs were to be met. Health care needs were met but care must be taken to review risk assessments and to show how these would be managed. Management must ensure notifications are sent to the Commission in line with regulation 37. Medicine management was well improved and practice did not pose a risk to residents. Residents and relatives seen said staff treated residents with respect. EVIDENCE: Two residents’ care plans were viewed. Care plans were improving but still needed more work to ensure they provided adequate guidance for staff on how identified care needs would be met. For example the care plan for one resident suffering from dementia did not provide clear guidance as to how to manage this aspect of care. One resident who had lost a lot of weight had not St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 12 had their weight checked for over two months. Also residents assessed at risk of developing pressure sores did not have care plans in place to show how this risk would be reduced nor had the risk assessment been reviewed. Not all records seen had been named, dated and signed. The manager said that plans were in place to provide care plan training for staff. There was little evidence of resident involvement in preparing care plans. Residents and relatives seen said they were not formally involved with preparing care plans. Residents and relatives spoken with during the inspection said they were satisfied with the quality of care provided. Requirement 1. Residents were registered with a G.P and staff made arrangements for residents to access dental and optical services. The manager had completed a course on ‘foot care’ and provided this to all residents except those suffering with diabetes. Residents with diabetes received chiropody services through the NHS. Records were kept for all accidents to residents and those seen were well completed. Notices were not always sent to the Commission as required by regulation 37. For example when residents were ill and admitted to hospital or when they sustained an injury from an accident in the home. Requirement 2. At the time of this inspection none of the residents managed their own medicines. Medicines were safely stored and a medicine fridge was provided. Administration charts were well maintained but care must be taken to ensure had written entries made by staff on these were countersigned and reflected the information on the pharmacy label. Most of the requirements made at the last inspection in relation to medicine management had been met. Since the last inspection staff had received update training on medicine management. A new medicine cycle had just commenced and no errors were noted with medicines. Requirement 3. Residents and relatives spoken with during the inspection said staff treated them with respect. Staff were observed interacting appropriately with residents, answering call bells and responding to resident requests for assistance. St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12- 15 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Some activity hours were now allocated and residents were very pleased with this change. Residents and relatives seen said visitors were made to feel welcome and residents indicated they could make choices about their lives. A new chef had been employed for five days a week and again residents were pleased with this change. EVIDENCE: Residents were seen sitting in the lounge watching T.V., or in their bedrooms or having their hair done. A hairdresser visited every Friday and residents said how much they enjoyed having their hair done. Improvements had been made to activities provided and a care assistant now had two hours a day five times a week to organise and run activities. Residents seen said they enjoyed the new system to provide activities and many said they participated in these. Activities arranged included arts and crafts, hand massage, gently exercises, quizzes, board games and others. The new carer took some residents out for a short walk weekly and this was something residents said they particularly St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 14 enjoyed. Individual activity records were kept but social care plans could be further development. The home had an open visiting policy and residents said they enjoyed visits and outings with family and friends. Visitors seen said they were made to feel welcome by staff when visiting the home and were kept informed about their resident’s welfare. Residents said they made decisions as to how they spent their day and how they liked to dress and present. They also had a choice of meal. By involving residents more with care planning the home could evidence the level of personal choice residents made. (See requirement 1.) A new chef was employed since the last inspection. He worked five days a week. Residents were very positive about the new chef and with the meals provided. A number of residents said the food was ‘very good’. Staff held a meeting with residents to discuss their views about meals, and residents said they would prefer to have a roast dinner on Sunday instead of Monday. This request was met and residents were pleased with this. Also since the last inspection the menu had been changed to include a cooked meal option at suppertime. Residents had a choice of meal both at lunch and suppertime. During lunch it was evident residents enjoyed their meal, had a choice of meal and staff offered assistance where needed. St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 – 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate procedures were in place to receive and manage complaints made about the service. The adult protection policy had been amended, a copy of the local authority’s adult protection procedures was provided and most of the staff had received update training on this topic. EVIDENCE: The home had an adequate complaints policy in place and a system to record complaints made about the service. Since the last inspection no complaints had been made about the service to the home or the Commission. Residents and relatives spoken with said if they had a concern they would discuss this with the manager or a member of staff. The adult protection policy and procedure had been reviewed as advised at the last inspection and now provided clear guidance for staff. A copy of Bexley’s adult protection procedures were provided and most of the staff had received training on adult protection since the last inspection. In discussion with staff it was evident they had an understanding of adult protection and what to do if this was suspected. St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,24 &26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. The home was clean and tidy. Residents seen were satisfied with the environment. The registered person must consider upgrading the décor of the home particularly the communal areas. EVIDENCE: The home was adequately maintained but the environment was looking tired and dated. Following the last inspection the Commission were told that plans were being put in place to start a redecoration and refurbishment programme. It was disappointing to note that on this occasion the inspector was told that these plans were ‘on hold’. No changes had been made to the small lounge. Even the addition of curtains to this room would make it more homely and user St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 17 friendly for the residents and provide an alternative area to relax in. At the last inspection the registered person agreed to send a programme for the refurbishment work to the Commission including the planned start and finish dates. As this was not done the requirement has been restated in this report. Staff recorded repairs and maintenance issues and when the maintenance technician visited and completed the work he indicated this had been done on in the maintenance book. Requirement 4. The home had adequate numbers of bathrooms and toilets. One bathroom had an assisted bath but the second one did not and was rarely used, as it was not suitable for the majority of the residents. As the home had only two bathrooms consideration should be given to refurbishing the second bathroom to make it more suitable for the residents. Recommendation 1. Bedrooms seen were clean, tidy and free of offensive odours. Residents seen said they were satisfied with their bedrooms and were able to bring in small personal items such as photographs, ornaments, pictures and small furniture items. Bedrooms were adequately decorated and many seen were nicely personalised. The home was clean, tidy and free of offensive odours. One domestic member of staff was employed who did the cleaning and laundry. As cleaning took up a lot of time care staff now assisted with doing the laundry. The manager should ensure this does not affect the care provided to residents. Hand washing facilities were provided in areas where waste was handled. Recommendation 2. St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels were maintained. Six care staff had enrolled on an NVQ 2 course and once they completed this, the home would have 50 of care staff with the qualification. Although improvements were made to recruitment procedures these needed further work to fully comply with regulation. Improvements had been made to staff training and a number of staff had received training relevant to their work since the last inspection. EVIDENCE: The staff team comprised of a manager, senior carers, care assistants, domestic staff, a chef and allocated activity organiser hours. A maintenance technician visited the home on request to undertake repairs and health and safety work. Staff rotas seen showed that adequate staffing levels were maintained. Staff displayed an understanding of the residents and their care needs and were observed interacting with them appropriately. Comments made by residents included ‘staff are very helpful’ and ‘staff are very good’. Senior staff in the home planned to retire in 2008 and therefore had decided not to complete NVQ training. They did however attend update training relevant to their role. Three of the remaining twelve carers employed had St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 19 achieved NVQ 2 or above. Since the last inspection six care staff had enrolled on a course to complete NVQ 2. Recruitment procedures had improved since the last inspection. Four employee files were viewed and found to contain most of the information required by regulation. It was disappointing therefore to note that since the last inspection one employee had commenced work in the home even though only one written reference had been obtained. The registered person must ensure references not received on headed paper, received without a company stamp or without a compliment slip are verified as genuine. Also when an employee’s last role was working with vulnerable people a reference must be obtained from that employer. An induction booklet had been introduced but there was no evidence to show that these were being completed with staff. Requirement 5. There was evidence to show that staff had received training on medicine management, adult protection, diabetic care and fire safety since the last inspection. The manager said that training on basic first aid, dementia care and moving & handling was planned for staff in November and December 2006. Staff seen said how much they had enjoyed and benefited from the training they had received. St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 .Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements had been made to the overall management of the service. The registered person provided reports to the Commission as required by regulation 26. The manager had started a quality assurance system including a relative satisfaction questionnaire and had held resident and relative meetings. Staff did not receive formal supervision. Safety records seen were up to date and showed attention was given to providing a safe environment. EVIDENCE: The registered manager had been in post for a number of years and had the experience needed to manage the service. The manager said that as she planned to retire in 2008 she did not intend to undertake any NVQ training. St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 21 The manager had worked with the Commission to meet and meet and raise standards in the home. Since the last inspection the Commission received reports in relation to regulation 26 visits by the registered person, the manager had held resident and relative meetings and had prepared and sent out a relative satisfaction questionnaire. The manager planned to develop a satisfaction questionnaire for residents and to send these and the relative ones out annually. The relative questionnaires returned provided useful feedback on the service provided. The manager had not collated this information as yet nor prepared an action plan based on the survey findings. Once this was done a copy of the prepared action plan would be sent to the Commission and made available to residents and others. Residents and relatives seen mentioned the meetings and seemed pleased to have had the opportunity to voice their opinions of the service and to give feedback and make suggestions to management. Management did not provide assistance to manage resident personal finances. Relatives purchased personal items for residents and paid directly for services such as hairdressing. The manager confirmed that all residents had access to their personal allowance and some residents kept small amounts of cash for personal use. No staff supervision had been provided since the last inspection nor had a policy and procedure been implemented in relation to this. The manager and senior staff worked with carers and took the opportunity to supervise practice; this supervision was now being recorded. Requirement 6. A selection of safety records were inspected, these included gas, electricity, portable appliance testing, fire safety, hoist service, lift service and water chlorination. All records seen were up to date. Since the last inspection a fire risk assessment for the building had been completed, staff had fire safety training provided by an appropriate person and fire drills were held at time to include night staff. A system had been introduced to record checks on hot water temperatures and records seen showed precautions were taken to ensure these were maintained at safe levels. St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 3 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION score Standard No 16 3 17 X 18 3 2 X 2 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 1 X 3 St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The registered person must ensure care plans are prepared for each resident to show: • How all identified care needs will be met. • Provide evidence of resident involvement with preparing these. • Show how identified risks will be managed. • All care documentation must include the residents name and entries signed and dated by staff. The registered person must ensure notifications are sent to the Commission in line with the requirements of this regulation. The registered person must ensure hand written entries made by staff on medicine administration charts are countersigned and reflect all the information on the pharmacy label. The registered person must ensure a copy of the programme for the planned redecoration and refurbishment work sent to the DS0000006785.V320301.R01.S.doc Timescale for action 18/12/06 2. OP8 37 18/12/06 3. OP9 13 18/12/06 4. OP19 23 18/12/06 St Margaret`s Ltd Version 5.2 Page 24 5. OP29 19 6. OP36 18 Commission. (Timescale of 27/07/06 was not met.) The registered person must not 18/12/06 employ staff to work in the home unless all the information required in schedule 2 has been obtained. (Timescales of 13/03/06 17/07/06 were not met.) The Registered Person must 18/12/06 ensure the home has policies and procedures in place in relation to staff supervision and that staff receive supervision as required by regulation. Evidence of staff supervision must be kept and made available for inspection. (Timescales of 27/03/06 and 27/07/06 were not met.) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP21 OP26 Good Practice Recommendations The registered person should consider refurbishing the second bathroom in the home to make it more suitable to meeting the needs of the residents. The registered person should review the practice of care staff doing laundry to ensure this does detract for the care provided to the residents. St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Margaret`s Ltd DS0000006785.V320301.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!